Black and Blue Report: November 24, 2009

by Will Carroll

Matthew Stafford

The first thing to clear up is that it was Matthew Stafford that ran back on the field. It wasn't the coaches, but the medical staff didn't stop him either, so if this ends up being a bigger issue, there is some blame there. The result is good, but a meaningless win against a bad team really doesn't mean much in the longer term. Stafford's non-throwing shoulder is being described as "mangled" and it's clear that it was a dislocation. This is much like the situation with Sam Bradford, but on the non-throwing side. Stafford's time missed will depend on how much damage was done internally -- were ligaments, tendons, and the capsule stretched or torn? Early reports are that the shoulder didn't take much damage, but with a short week, it's unlikely he'll play against the Packers. There are other quarterbacks who have had problems with the off-shoulder and come back, but keeping Stafford upright is going to have to me even more of a priority if he comes back this season. Yes, that's a question right now.

Kurt Warner

Roger Goodell is playing the patriot card, bringing the U.S. Military in on the concussion discussion. Both the NFL and the military have a lot of problems with head injuries, and when you consider what the military is doing in Iraq and Afghanistan, I'm not sure that's a good comparison for the NFL: Safeties are doing the same kind of damage that bombs are. Warner's concussion -- and no matter what the nomenclature, he had some sort of concussion -- appears to be mild, though the Cardinals will be watching closely. With the division all but wrapped up, it's time for the Cardinals to protect Warner and figure out if Matt Leinart is anything besides fodder for Deadspin. While Warner is saying he'll play in Week 12, note that the Cardinals were very conservative with injuries at this stage last year.

Ben Roethlisberger and Charlie Batch

Mike Tomlin called Ben Roethlisberger's injury "concussion-oriented." While Goodell is moving towards the independent neurologist model I called for in Pro Football Prospectus a few years ago -- you're welcome, NFL -- Tomlin's off-hand comment shows us what might happen. As in Rugby, which also uses this model and had required time off after concussions, hiding the injury got to be a bit too popular. Roethlisberger's such an interesting case, given the problems he's had with his head on and off the field, plus descriptions of him as moody and forgetful from insiders. While he'll likely play this week, assuming he passes some cognitive tests, the Steelers are a bit worried that with Charlie Batch done for the season with a broken wrist, they don't have much in reserve. Dennis Dixon, who is perhaps better known for playing through a torn ACL in college than his quarterbacking, would be the backup.

Marc Bulger

Say it with me: He didn't get his "bell rung," as was said in the press conference. Marc Bulger suffered a concussion and will be monitored closely. Look, I'm as sick of talking about this, sounding like Debbie Downer every week, but this just keeps happening. Bulger's head will be tested Tuesday, but the more immediate problem is a leg injury that sounds pretty nasty. When you hear a player describing the injury as "burning" or "like a bite out of it," that's telling. I'm sure you're saying "Will, you always say players aren't credible sources on their own injuries." Let me clarify this. Players are terrible at diagnosing themselves, saying what's wrong or whether they'll play. They're great at describing or reacting to pain. No one knows more about Bulger's leg than Bulger. Watch any play -- one of my faves from yesterday was the great shot of Ray Lewis rolling his ankle and immediately grabbing at it, then looking around to make sure no Colts saw -- and you'll see reaction. Late word is that Bulger has a fractured leg, though no one seems to know exactly what's broken, or where. Remember, Steve Spagnuolo discussed a "groin-hamstring" strain. Kyle Boller may be getting more action over the rest of the season with Bulger likely headed to IR.

Ladell Betts and Clinton Portis

There's not much going right in Washington these days. Forget Harry Reid, I'm talking about the Redskins, where the running game is down to Rock Cartwright after a brutal, twisting knee injury gave Betts the full triad -- he's torn both his MCL and ACL, plus the associated meniscus damage. While an ACL injury takes about a year to come back from, with some variance between the time a player can play and the time he feels "full go," the triad tends to take even longer. At 30, the career backup may not be able to lose a step and continue. The Redskins don't expect Clinton Portis back soon, since he's still having severe vision issues and headaches as the result of his concussion. There's some discussion going on about the IR, though I'm told that move will only come if the team feels the need to sign another running back. There's not much depth or upside back there right now.

Michael Turner

The Falcons are tipping that Michael Turner will be back at practice this week, with a chance of playing in Week 12. This after a solid performance from Jason Snelling. Not that there's a chance Turner isn't significantly better than Snelling ... or is he? Remember, it was LaDainian Tomlinson holding Turner back from showing that maybe, he was the better choice all along. Any high ankle sprain tends to take about four weeks to heal, but we've seen more and more players trying to come back before then. The case of Anquan Boldin is perhaps the best known and while the two players have different demands, it's hard to see how Turner will have better results here. He's not going to be 100 percent, and Snelling was relatively effective, so this move might make both poor fantasy options against Tampa.

Aaron Kampman and Al Harris

The Packers got the double whammy, losing two key defenders ahead of a short week. Both Aaron Kampman and Al Harris tore their ACL and will be done for the year. For Kampman, it could end his Packer career, given a lot of complex circumstances. In the immediate future, the team's just going to have to adjust, hoping that depth can handle things while the Packers cling to a playoff spot (They're tied for the last Wild Card spot in the NFC, though I didn't dig through the tiebreaker scenarios with six games left). Both players should be able to come back, even with Harris at 35, though it will be interesting to see how the new normal timeline of six to eight months for an ACL will play out here.

Bumps and Bruises:

Brett Favre's hip is about as serious as Eli Manning's foot. Annoying, yes. Debilitating, no ... Tony Romo had severe back spasms, necessitating a painkiller injection to "unlock him." This is said to be "not uncommon" by a team source and may speak to his longevity ... Marshawn Lynch's shoulder injury doesn't appear to be structural, but even if he plays, expect his workload to be down ... Brandon Jacobs was off the field at the end of Week 11, but made practice, so things look minor for whatever the knee problem was ... Cedric Benson's hip flexor is still an issue and his availability will be determined by Friday ... Steven Jackson has a lower back strain. While expected to play, this could affect his workload ... Ryan Grant had a stinger, but should be fine for the next game ... Reggie Bush gets an extra day to be ready for a huge Monday night game with the Pats. The Saints expect his knee to be ready ... Details are sketchy, but it appears Calvin Johnson injured his knee on that desperate last play of the game. Johnson has every skill but health ... Did anyone outside of Minneapolis know the Dome is now "Mall of America Field?" ... Sounds as if Chris Cooley is headed for the IR. He's not healing fast enough and the Redskins are going nowhere ... Chargers offensive tackle Jeromey Clary was playing on a bad right ankle. During Sunday's game, he tore ligaments in his left ankle. Now he's likely done for the season, though there's a possibility he could be back for the playoffs ... Ouch! Bills guard Eric Wood broke his tibia and fibula Sunday and had surgery. His season is done ... Skins guard Chad Rinehart broke his fibula and is done ... Brian Dawkins has a short week and a neck injury, a tough combo.

Would gladly accept the sponsorship over the current nuisance of having to move my cursor to the side to avoid having the annoying pop-up ads appear if I'm unlucky enough to roll over a players name. Navigating long Football Outsiders articles is a bit like a maze.

noscript is your friend. Assuming you're using firefox anyway. I do worry that I'm somehow depriving FO of ad revenue by using it, so sometimes enable it temporarily, but those rollovers are so annoying that I always go back.

There was an addon I saw somewhere that somehow acted like you saw the image and even clicked on the link invisibly so you didn't see it, but got the site you wanted to support credit for so doing, which seems to me to be the best of both worlds (except to the advertiser, but hey, make your ads less annoying).

The Colts have hinted at a long injury report this week and have opened roster spots IRing Dan Federkeil (second time in 3 years he's been IRed with a concussion) and waiving Mike Hart. Any news on who has the issue or do I just have to wait for the report tomorrow?

Pedantry: The Packers are tied for the first and last playoff spots in the NFC. If the season ended now, they'd take the #6 seed: their conference record (5-3) is inferior to Philadelphia's (5-2) but superior to New York's (4-3).

Interesting that you think Kampman is done in Green Bay, but not Harris…

Curiously, both leagues have a three-way wild card tie at 6-4 right now - if I'm reading the procedure right, Philly and Green Bay are currently in for the NFC, and Jax and Denver for the AFC. (The Giants go down at the first tie-breaker, having lost once to the Eagles; the Steelers go down at the second, conference record, despite beating the Broncos, because neither has played the Jags.)

Actually, maybe I wasn't reading it right - Jax does hold the #5 by virtue of conference record, but then the process resets, and Pittsburgh holds the #6 by virtue of head-to-head over Denver, which trumps Denver's better winning pct in conference games. Funky.

Merely contracts. Harris is signed beyond this year, Kampmann is not and will be coming off a devastating knee injury. Not sure GB will take the risk and in uncapped year, I'm guessing some team will outbid them.

Goodell going to the military bothers me on a couple of levels (not least the sincerity level), but I have to wonder how medically valid the gesture is.

Boxers suffer frequently repeated moderate (relatively) blows to the head; football players may be subject to multiple blows to the head, which are typically much more devastating individually, but not anywhere near as numerous. Medical studies suggest that the long term effects of each of those are generally quite different.

Soldiers rarely suffer a significant blow to the head, their concussions are most often from the concussive effects of a detonation, and are not often repeated. I suppose it's possible that the results of each type of injury are nearly identical and are treated in the same way, but I rather suspect that is not precisely the case.

In any event, in my experience military doctors are pretty forthcoming about the results of their own studies and experience. This isn't secret military stuff that the NFL needs to go extract. Any neurologist who makes a study of concussions almost certainly has access to all of this information already. Common sense would suggest that doctors whose focus is already on the precise type of head injuries that football players encounter (and I suspect there are a lot of them) would be in the best position to make recommendations about prevention and treatment.

I assume you are referring to this phrase in that report: "and it appears that multiple blast traumas are much more common than multiple sports concussions."

I would like to know exactly what they mean by that. Do they mean some level of what they describe as a 'Primary blast,' i.e. close enough to 'feel' the effects of the blast to some extent? If so, yes I can believe that, but I also don't think that that is generally anywhere close to the effects of a helmet to helmet or knee to helmet hit that leaves the player dazed and confused and possibly briefly unconscious.

I suffered what they describe as a 'Tertiary blast' in 1970. In fact, due to circumstance (sitting down with my backpack and helmet on), my head was probably about as close to the blast point of an 82 mm mortar round as one could hope to get and still be around to tell the story. Despite also incurring multiple shrapnel wounds to my head (penetrated the helmet) and being tossed about 10 feet down a hill, I was nonetheless fully conscious, cognizant and mobile in less than 30 seconds after the blast. I think I probably could have named the president at that point, though I don't think anyone asked.

My observation of football suggests to me that the strictly concussive part of that incident was more or less equivalent to a bad helmet to helmet hit in the NFL. I can promise you that I was never going to be in a position to suffer a second one like that, but NFL players often are.

As to the 'close enough to feel it' types of blasts, sure - that can happen a lot and did, but I guess I just don't think those are typically serious enough to do any real damage or have long lasting effects; most don't have any significant short term effects that I recall. I know I could be wrong. To the best of my knowledge I have suffered no long term effects from either those or the more serious incident (though I never played the violin again).

I still stick to my suggestion that the medical information is readily available whether there is direct collaboration or not. And I was certainly disingenuous in not mentioning my primary negative reaction to this story, which is the NFLs continued attempt to use the military to prop up their image.

But I'll back off on any more attempts at medical conclusions or comparisons of military/football injuries. I really don't know and could be completely off base.

The lack of strong medical evidence about any of this is remarkably stunning both in sports and in the military world; consequently, this partnering is rather significant as it both acknowledges that this could be a problem and that there is a lot we don't know.

"'close enough to feel it' types of blasts, sure - that can happen a lot and did, but I guess I just don't think those are typically serious enough to do any real damage or have long lasting effects"

I think that is the common thinking up until recently, now there is concern that for at least some people, these effects may be cumulative.

I should also note that one thing I was not considering was the effects of concussion for soldiers inside a vehicle, as with encountering an IED. That is not something we ever had to deal with and I would immediately suspect that the concussive effects in those circumstances are probably significantly more serious. I guess I wasn't thinking clearly.

Mechanisms inside a vehicle are very complex. When an IED goes off under an MRAP, for example, a lot of stuff happens. The blast could penetrate the armor, in which case you might get shrapnel flying around inside, and huge pressures, and it's a bad day for everyone inside. However, even if the armor isn't penetrated, you could still get shrapnel (the back side of the armor can actually spall and create high speed debris inside the vehicle), and you still get pressure--a large blast can deform a steel plate inches thick by several inches in mere microseconds...which acts like a big plunger that can break the leg of anyone standing on it, and creates a pressure shock wave that will be felt by everyone inside. In addition, the whole vehicle is jolted, so guys inside could get thrown around. So anyone inside could have their head knocked against a wall/support, could have a piece of shrapnel hit their helmet at high speed, and could feel a pressure blast wash over them. In fact, I think the majority (not overwhelmingly so, but the majority nonetheless) of brain injuries suffered by the army are by guys in vehicles hit by either IED's or RPGs.

I suffered what they describe as a 'Tertiary blast' in 1970. In fact, due to circumstance (sitting down with my backpack and helmet on), my head was probably about as close to the blast point of an 82 mm mortar round as one could hope to get and still be around to tell the story. Despite also incurring multiple shrapnel wounds to my head (penetrated the helmet) and being tossed about 10 feet down a hill, I was nonetheless fully conscious, cognizant and mobile in less than 30 seconds after the blast. I think I probably could have named the president at that point, though I don't think anyone asked.

Man, that must have been one scary experience! But it actually brings up a good point about why the army has seen TBI on the rise in recent conflicts, and it's not just because we're up against fewer bullets and more IED's.

Body armor has gotten a lot better since our last major war, Vietnam. So have on the field triage, and battlefield evacuation capabilities. Guys survive blasts now that would have been fatal back in 1970...maybe because their body armor protected them from shapnel that would have penetrated Vietnam era armor, maybe because the medics saved the guys that were in critical condition on the field better than the medics could in 1970, and maybe because those guys can be in a field hospital in mere hours, and a full hospital in Germany in less than a day, after injury, whereas in the 1970's they could be injured in the field, or in a place with more limited medical capabilities, for a lot longer. So soldiers that would have died back then are surviving now...but surviving with TBI.

I don't know about "empty gesture at best". It may or may not be particularly effective. But even if it's not, it highlights that the NFL is finally starting to acknowledge the seriousness of the situation -- that safeties can cause the same type of damage as explosions, as Will put it. That's a marked departure from their past stance on the issue, even as recently as a couple years ago.

Very good discussion on this topic. I have a few things to add (I've actually been studying military blast-induced TBI for a couple of years now).

First off, you have to understand that, while the symptoms associated with a "concussion" are relatively agreed on by most doctors (although they do vary widely), the specific medical injuries that cause these concussions are not. If you ask four different doctors to define how they diagnose "Traumatic Brain Injury", you'll get four different answers (including some from a small but still vocal minority that insists that there is no such thing as mild traumatic brain injury in soldiers and everything that's being called that is a new form of PTSD). I was recently at a traumatic brain injury conference, and asked the doctor sitting next to me what she thought the single most important advancement in the field of soldier TBI could be...I was expecting an answer like a special machine that could scan brain tissue, or a better helmet, or something...and she responded "a consistent definition of TBI that all doctors agree on". The thing is, the medical data you talk about that's available to everyone isn't really useful for epidemiological analysis (i.e. figuring out how repeated different levels of exposure need to be to cause injury), because the source terms aren't well characterized (you never know how bad of a blast a soldier was in, or whether he also got slammed into the wall of a humvee, or whether a chunk of shrapnel or concrete ricocheted off his helmet), and the result terms aren't either (with fifty different definitions for TBI and no consensus on characterizing the symptoms, you'll get fifty different descriptions of the same injuries). Some TBI has been related to specific medically-detectable damage types in the brain (e.g. diffuse axonal injury, contusions, or hemorrhaging), while others haven't been.

The other problem with dealing with military studies of head injury in the football world is that there are different operative physics mechanisms. This is more the area that I study. Most of what we know about head injury comes from years of study of automotive injury data, with some animal testing data and, just now, a bit of sports injury data starting to work its way in. All these scenarios are dominated by linear acceleration of the head, sometimes with rotation on top of it--which results in the brain bouncing around and hitting the skull, inducing shear strain in the brain tissue, tearing bridging veins, and bruising on the surface. This type of injury can certainly occur in a military environment--a soldier can be thrown against a building or the ground or the inside of a humvee. But so-called primary blast--the effects of blast pressure alone--are also thought (although not know for sure) to cause TBI. There is data that military "breechers", guys that regularly set off small explosive charges with no shrapnel to blow open doors and such, start to have brain trouble because of repeated exposure to small explosive blasts. But the acceleration associated with any primary blast that's small enough not to turn your lungs to jelly and destroy your eyeballs are very small--so small that metrics the automotive industry uses to characterize linear acceleration injury say that they are completely harmless. Instead, something about the pressure wave itself may be causing brain injury in soldiers (exactly how is still debated...theories include the generation of a pressure surge from the chest that get's transferred to the inside of the brain, and direct action of the pressure on the skull causing dynamic bending of the skull and pressing on the brain). If this is the case, then trying to draw comparisons to sports injuries is inappropriate, because there are not pressure waves acting on the skull or body when two football players collide.

While mechanism of injury is not completely irrelevant, parallel paths of research seems appropriate, since the question remains what is the proper way to manage mTBI after it occurs, and what are the effects of repeated mTBI?

I've never seen other reports that Roethlisberger is "moody and forgetful" ... other than the caricatures on KSK, I don't read much about Ben's off-field personality anywhere. I'd be curious to see something a bit more solid than this.

Any news on Antoine Winfield? It seems like the Vikings are willing to let him rest if they feel he's not needed to win a game, and I appreciate that, but he's been out a long time for something that sounded pretty mild when it happened.

Childress said that cornerback Antoine Winfield (foot) wanted to play Sunday but the decision was made to sit him for the fourth game in a row. "He's close," to returning, Childress said. "I'll just say that."

FWIW Karl Paymeh, who looked like a total liability when pressed into the starting lineup vs. the Ravens, has held up alright. He's no winfield, but I feel this time will help when Winfield does come back...

Yeah, and it also has allowed Asher Allen to get some time, which may be helpful down the line. When Winfield gets back, and the Vikings are playing teams like the Cards or Saints in the playoffs, Frazier could do a lot of stuff with two, or even just one, linebacker on the field, even on first down, knowing how good good Winfield is against the run.

Interesting. I think it could be beneficial to have some goofy looks on defense, but I don't know how often I would call it an advantage to have Paymah and/or Asher Allen on the field in place of one or two of the starting LBs, who are, in my opinion, very solid players.

It's fun to think about, though. I'll wait and see if anything like that happens.

Back to football...both Warner and Roethlisberger apparently suffered concussions, and both their respective teams are trying to dodge the new rule by referring to their injuries as "concussion oriented". The question is...will "Iron Goddell" come down on the Cards or the Steelers if Warner or Roethlisberger play this week, especially if they don't consult an independent neurologist? It seems like they're blatantly flaunting his authority right after he makes a decree and, if Roethlisberger, for example, suffers any lasting injury from playing concussed, right after Goddell makes a big hubbub about caring about player health (and right after the chairs of the league's concussion panel resigned!), it could make him and the NFL look really bad.

Other coaches and players have been given huge fines and even docked draft picks for doing exactly that...defying Goddell's rulings and making him and the NFL look bad. How does he play the concussion thing...

I can't speak for the Cardinals, but Tomlin was absolutey NOT trying to dodge the new rule by referring to Ben's injury as "concussion oriented". From his press conference yesterday:

Did Ben Roethlisberger officially sustain a concussion?
You know, it could be characterized as a mild concussion; I hesitate in terms of using the word mild because concussions aren’t anything to be taken mildly. He was symptomatic at the game, that’s why after the game I said he was down with concussion-like symptoms. When we were able to do appropriate testing yesterday, he was symptom-free, he felt fine, so we’re proceeding with caution, but we will continue to monitor him each and everyday this week as we push forward towards game day because if any symptoms reoccur or he feels less than fine, then of course we’re going to act appropriately.

As far as dealing with Ben [Roethlisberger] and his symptoms, before you got here in ‘06, he tried to play through a lot of that-the car accident, the hit in Atlanta. How convincing does he have to be to you given that?
I’m not acting on Ben convincing me of anything. We have independent medical experts, Dr. Maroon and company, who are recognized internationally. People in our business in this league fly players in from other cities to see those men. We listen to them first and foremost. We have a great deal of confidence and comfort in their expertise and at this point, they are comfortable with saying that he is symptom-free. That would be the utmost determinant in terms of how capable Ben is of participating, leading up to this game and also in this game.

Long-term damage aside, I don't understand how Big Ben and the rest of the all-concussion squad can do it.

I suffered a concussion when I was in high school and it has got to be the most miserable injury I've ever had. It just keeps going and going.

Even seven days afterward, I don't care how much you paid me, there was no way I could run full speed down a football field; much less be knocked to the ground by an angry gentleman forty pounds heavier than me.
Well, I could have done it once. After that, I would have just curled up in a ball and cried like a baby.